The ride application

Dear RIDE Applicant:

Thank you for your interest in THE RIDE, the MBTA’s shared-ride, door-to-door transportation program for persons who are prevented from independently using the fixed-route services such as buses, subway trains, and trolleys (not including commuter rail and boat) due to barriers in combination with their disability(ies) for some or all trips. Please have the application fully completed by you and your licensed/certified human services or health care provider prior to returning it to us. All information provided is confidential and serves to determine eligibility only.

Sincerely,

Office for Transportation Access—THE RIDE Program

Visit our website for more information about THE RIDE at www.mbta.com, and then navigate to “Riding the T—Accessible Services—THE RIDE”. If you have any further questions or require an accommodation, please call the Office for Transportation Access—THE RIDE Program, at 617-222-5123 (Voice), 800-533-6282 (Toll-free Voice), 617-222-5415 (TTY), or email [email protected]. We look forward to ensuring that public transportation is available for persons of all abilities.

INSTRUCTIONS PAGE 1

http://www.mbta.com/traveling_t/disability_theride.asp

mailto:[email protected]

INSTRUCTIONS FOR THE RIDE APPLICATION

Please complete each section. If there are questions that you do not understand, please do not hesitate to call 617-222-5123 or email [email protected]. The purpose of this application is to identify the functional limitations and barriers which prevent you from independently using MBTA fixed route services buses, subway trains, and trolleys (not including commuter rail and boat) some or all of the time. It is important that you and your licensed/certified human services or health care provider supply specific, detailed responses so we may understand your abilities and assess your eligibility.

• You, the applicant, should complete pages 1 through 7 of the application. • A licensed/certified human services or health care provider only needs to

complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsy or Seizure Disorder, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if applicable.

• Examples of professionals include: Medical Doctor, Psychiatrist, Psychologist, Social Worker (LSW, LCSW, LICSW), Rehabilitation Professional, Physical/Occupational Therapist, Certified Orientation and Mobility Specialist (COMS), Physicians Assistant, Nurse Practitioner, and Registered Nurse.

• Please attach any documentation that should be considered as part of the application for Paratransit eligibility.

• When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE

Ten Park Plaza, Room 5750, Boston, MA 02116

INSTRUCTIONS PAGE 2

ELIGIBILITY CRITERIA

The RIDE adheres to the American with Disabilities Act (ADA) of 1990 eligibility standards for paratransit services. The law is specific in defining eligibility for ADA complementary paratransit services. A person must have a physical, cognitive or mental limitation, which prohibits his/her independent use of accessible fixed route public transportation. Category 1 Individuals who, as the result of a physical (including visual impairments), mental, or emotional impairment, and without the assistance of another individual (except the operator), cannot board, ride, or disembark from an accessible vehicle some or all of the time. Category 2 An individual who can independently use an accessible vehicle, but none is available on his/her route some or all of the time Category 3 Individuals who have a specific-impairment related condition that prevents getting to/from a stop within the service area some or all of the time.

Eligibility criteria does not include: Age, lack of service in your town, beyond ¾ miles from fixed route services, inconvenience, discomfort, financial status, or ability to drive. A diagnosis of a potentially limiting illness or condition is not sufficient; you and your provider must describe how your disability prevents you from getting to, boarding/disembarking, and/or riding on fixed route transit services independently. When completing your application, assess your potential travel throughout the entire bus and/or rail system during all seasons, not just those in your immediate neighborhood or those that you normally use.

INSTRUCTIONS PAGE 3

APPROVED CATEGORIES OF ELIGIBILITY

Once determined eligible for the MBTA RIDE Paratransit service you will be assigned an eligibility category. The eligibility category is consistent with your ability to use fixed route transit. These categories include: Unconditional - Individual is not able to use accessible fixed route transit under any circumstances and is eligible for all trips on the paratransit service Conditional - Individual is not able to use accessible fixed route transit in specific circumstances and is eligible to use the paratransit service under limited circumstances identified. For example, conditional categories include: • Night: Individual is eligible for service from dusk to dawn. • Heat: Individual is eligible for service when temperatures are above

80 degrees. • Cold: Individual is eligible for service when temperatures are below

35 degrees. • Snow/ice: Individual is eligible for service when snow or ice is

present. • PCA Always: Individual is required to travel with a personal care

attendant for safety. • Met on Both Ends: Individual is required to be met by someone at

pickup/drop-off locations for safety.

Temporary - Individual is not able to use accessible fixed route (bus, train, trolley) transit at this time, however the condition or circumstance(s) leading to eligibility is reasonably expected to improve in the future.

INSTRUCTIONS PAGE 4

APPLICATION SUBMISSION

Once your application is received, the Eligibility Review Committee will review it. After the eligibility determination is made, we will notify you in writing. Please allow 21 days from the day we receive your completed application for processing. Call the Office for Transportation Access if you have any questions about the decision. If your eligibility determination has not been made within 21 days of receipt of your completed application, you will be granted THE RIDE service until the determination is made. If you have any questions about the application or you want to check the status of your application, contact the Office for Transportation Access at 800-533-6282 (Toll-free Voice), 617-222-5123 (Voice), or 617-222-5415 (TTY) for the deaf and hard of hearing.

ABOUT THE RIDE SERVICE

The MBTA's paratransit service, THE RIDE, provides advance notice, shared-ride, door-to-door transportation to those who, because of a mental, physical or cognitive disability, are unable to use fixed-route public transportation. As a customer of this shared-ride service, you will travel with other passengers on vehicles that operate within a 60 city and town service area. (See enclosed listing of communities). Greater detail on use of the service will be provided upon completion of the registration process.

INSTRUCTIONS PAGE 5

ADDITIONAL MBTA RESOURCES AND CONTACTS

• Visit www.mbta.com for transit updates, accessibility, and travel information

• Call our Customer Communications Center at 800-392-6100 (Toll-free Voice), 617-222-3200 (Voice), or 617-222-5146 (TTY) for accessibility related questions concerning MBTA buses, subway, commuter trains or boats, or for travel information.

• MBTA Senior and Access Program Information

o www.mbta.com Riding the T Accessible Services Reduced Fare CharlieCard (buses, subways and trains, commuter rail and boat) for seniors and persons with disabilities are available at Back Bay Station on the Orange Line. For information, call 800-543-8287 (Toll-free voice), 617-222-5438 (Voice), 617-222-5854 (TTY).

• Elevator / Escalator Update Line

o 800-392-6100, press 6 or www.mbta.com ‘Rider Tools’ o 617-222-2828 (Voice), 617-222-5854 (TTY),

Mon. - Fri., 8:30 a.m. - 5:00 p.m.

• The Access Advisory Committee to the MBTA (AACT) is a consumer body that advises and makes recommendations to the MBTA regarding accessible transportation. Anyone is invited to participate. The goal of AACT is to achieve 100% accessible transportation. AACT meets monthly at the State Transportation Building, 10 Park Plaza in Boston. For meeting information or to be placed on their mailing list call 617-973-7507(Voice), 617-973-7089 (TTY) or email [email protected].

INSTRUCTIONS PAGE 6

http://www.mbta.com/


http://www.mbta.com/riding_the_t/

http://www.mbta.com/riding_the_t/accessible_services/


mailto:[email protected]

CITIES AND TOWNS IN THE MBTA SERVICE AREA

Boston North GLSS

Northwest VTS

South JV

Allston Beverly Arlington Boston Back Bay Boston Bedford Braintree Brighton Chelsea Belmont Canton Charlestown Danvers Boston Cohasset Chinatown Everett Brookline Dedham Dorchester Lynn Burlington Dover Downtown Boston Lynnfield Cambridge Hingham

East Boston Malden Concord Holbrook Fenway Marblehead Lexington Hull Hyde Park Melrose Lincoln Medfield Jamaica Plain Middleton Medford Milton Mattapan Nahant Newton Needham North End Peabody Somerville Norwood Roslindale Reading Waltham Quincy Roxbury Revere Watertown Randolph South Boston Salem Weston Sharon South End Saugus Wilmington Walpole West Roxbury Stoneham Winchester Wellesley Swampscott Woburn Westwood Topsfield Weymouth Wakefield Wenham Winthrop

For information on Massachusetts cities and towns not serviced by THE RIDE program, visit massdot.state.ma.us/Transit and navigate to Regional Transit link, or call 617-973-7000 (Voice) or 617-973-7306 (TTY). Service availability, hours of service, fares and policies vary in other areas.

INSTRUCTIONS PAGE 7

http://www.massdot.state.ma.us/Transit

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INSTRUCTIONS PAGE 8

THE RIDE Paratransit Eligibility Application

Send original (not fax or copy) to: MBTA Office for Transportation Access Ten Park Plaza, Room 5750 Boston, MA 02116

Questions? Contact us at: [email protected] 800-533-6282, 617-222-5123(V) 617-222-5415(TTY)

I. GENERAL INFORMATION: PLEASE TYPE/PRINT CLEARLY Male

Applicant Name _________________________________________ Female First Middle Initial Last

Home Address________________________________________ Apt. _______

City __________________________ State________ Zipcode_________

Email ___________________________________Date of birth____ /____ /____ Voice Voice Voice

Phone ____________ TTY ____________ TTY______________ TTY Home Work Cell

Mailing address __________________________________ Apt.________ (if different than above) City ____________________________ State________ Zip code_________

Email _____________________________________________________________

Emergency contact:

Name _____________________________ Relationship to you______________ Voice Voice Voice

Phone ______________ TTY _______________ TTY _____________ TTY Home Work Cell

Preferred format for materials from us? Large Print Braille Other Audio CD Email/electronic

RIDE APPLICATION PAGE 1

MBTA Use Only I.D. #:_____________________ Date:_____________________

II. MOBILITY AID, DISABILITY, AND MEDICAL INFORMATION

1. Will you be traveling with a personal care assistant (PCA)?

Yes, at all times No Sometimes

Note: PCAs are not provided by the MBTA or RIDE contractors, but we will provide space on the vehicle for your PCA.

2. Do you use a mobility aid or device? Yes No

a. If yes, which mobility aids or equipment do you use? (check all that apply) � Manual wheelchair � Walker � Powered scooter � Powered wheelchair � Cane � Guide/White cane � Prosthetic device/brace � Crutches � Oxygen tank � Service animal (guide dog, etc.) Describe:______________________ � Other, please specify:______________________________________

b. Is your scooter/wheelchair wider than 30”?

Yes No I don’t know Not applicable

c. Is your scooter/wheelchair longer than 48”? Yes No I don’t know Not applicable

d. Is the combined weight of you & your mobility device more than 650 lbs? Yes No I don’t know Not applicable

3. Are you currently receiving a treatment/therapy that affects your functional ability to independently use the MBTA fixed route services?

Yes No If yes, which treatments are you receiving, and for how long? Treatment_______________________Duration__________________________ Treatment_______________________Duration__________________________


4. Please identify all conditions that prevent you from independently using MBTA fixed-route services such as buses, trolleys, subway trains (not including commuter rail) some or all of the time.

Neuromuscular: � Arthritis � Cerebral Palsy � Multiple Sclerosis � Muscular Dystrophy � Parkinson’s Disease � Paraplegia � Quadriplegia � Stroke/Cerebral

Trauma (Date of occurrence)________

� Other:_____________

Medical: � Cancer � Cognitive (D) � Diabetes � Epilepsy/Seizure

Disorder (C) � Hearing Impairment � HIV/AIDS � Kidney Disease/Dialysis � Lupus � Mental Health (D) � Surgery (Date)_______ � Visual Impairment (B) � Other:_____________

Cardiovascular: � Arteriosclerosis � Asthma � Chronic Obstructive

Pulmonary Disease � Congestive Heart Failure � Cystic Fibrosis � Emphysema � Heart Attack � Peripheral Vascular

Disease � Thrombosis � Other:_______________

A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsy or Seizure Disorders, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if you want to provide more information.

5. Is your functional limitation permanent? Yes No If No, what is the expected duration?

# of Months______ # of Years______ Unsure ______


III. FUNCTIONAL ABILITIES AND MOBILITY

6. Can you, with your mobility device (if applicable): a. Independently ask for and understand written or spoken directions?

Yes No Sometimes (Explain)_________________________

b. Independently cross the street? Yes No Sometimes (Explain)_________________________

c. Independently wait for 10 minutes without a bench or seating area?


d. Independently step on and off a sidewalk from a curb? Yes No Sometimes (Explain)_________________________

e. Independently board an MBTA bus or subway train if it has a lift/ramp/kneeler? (All buses are 100% accessible.)


f. Independently walk up and down a flight of stairs if there is a handrail? Yes No Sometimes (Explain)_________________________

g. Independently stand on a moving bus or subway train holding onto a handrail?


h. Independently transfer from one bus or subway train to another?


i. Independently recognize when it’s time to get on/off the bus/rail vehicle?


j. Independently safely travel through crowded and/or complex MBTA facilities? Yes No Sometimes (Explain)_________________________


7. How does your disability prevent independent use of the MBTA fixed route services?

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

8. To the best of your knowledge, under optimal conditions, approximately how far can you independently walk/travel outdoors? (with mobility aid if used) Less than one block 1-2 blocks (1/4 mile) 4 blocks (1/2 mile)

6 blocks (3/4 mile) 8 blocks (1 mile) I cannot travel alone outdoors

Please specify optimal conditions:____________________________________

9. What are the barriers in your environment that combined with your disability, prevent you from using the MBTA independently? Some examples may include:

Busy street to cross Steep hills Time of day Lack of curb cuts No crosswalk light Snow/Ice Construction No sidewalk/Sidewalk condition (Describe): _________________________ Other_________________________________________________________

10. Is your condition affected by weather? Yes No

If yes, please explain:______________________________________________ ________________________________________________________________


11. Which of the following best describes your use of MBTA fixed-route services, such as buses and subway trains?

I’ve never used the MBTA I’ve used the MBTA, but not since the onset of my disability:

0-1 years ago 1-5 years ago over 5 years ago I currently use the MBTA system:

Rarely sometimes/ occasionally frequently / all the time

12. Please explain your experiences/challenges/observations with MBTA fixed-route services?

_________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________

13. Have you ever received travel training to use the MBTA fixed route system

(bus, trolley, train)? Yes No If yes, when?_____________________________________________________ Did you complete the training? Yes No

14. If you currently do not use the MBTA fixed-route services, is there anything that might help you to do so? (Check all that apply) Mobility Device Route/Schedule Information Communication Aid Other_________________________ Orientation & Mobility Instruction or Travel Training

15. Which best describes your current living situation? Skilled nursing facility Assisted living facility Group home Other:____________ House, apartment Rehab hospital


16. Provide any additional information that explains your functional level of mobility or the barriers/conditions that prevent you from using fixed route services. (Attach as much documentation as you need) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ RIDE APPLICATION PAGE 7

Sign below to indicate that the information you have given is correct to the best of your knowledge. If you are unable to sign, you may have someone sign for you and indicate their relationship to you.

I understand that the purpose of this application is to determine if there are times when I cannot use MBTA fixed-routes, such as buses and subway trains, and must therefore use ADA Paratransit services. I certify, to the best of my knowledge, that the information in this application is true and correct. I understand that providing false or misleading information may result in a reevaluation or revocation of my eligibility.

X_______________________________ Date ____________ Applicant's Signature

Sign below to indicate permission for your health provider to release information for the sole purpose of facilitating your eligibility determination or providing you with transportation. If you are unable to sign, you may have someone sign for you and indicate their relationship to you.

I hereby authorize my Human Service or Health Care Provider to release any information necessary to determine RIDE eligibility to the MBTA.

X_______________________________ Date ____________ Applicant's Signature

Applicant’s Checklist: � There is a signature and date in both spaces above. � My completed portion of the application, with the appropriate Provider’s

Verification Form, has been given to my human service or health care provider.

� The Provider’s Verification Forms A-General Medical, B-Visual Impairment, C-Epilepsy & Seizure Disorder, and/or D-Mental Health or Cognitive, are complete.


STOP

NEXT SECTION TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY

MBTA RIDE GENERAL MEDICAL FORM A THE RIDE PARATRANSIT ELIGIBILITY APPLICATION

TO BE COMPLETED BY LICENSED/CERTIFIED HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY

By completing and signing this document, you the health care professional, certify the truth and accuracy of the information provided on this application, to the best of your professional knowledge. The American with Disabilities Act of 1990 requires that the MBTA provide services to persons who are unable to use the fixed-route system (such as buses, trolleys, subway trains, not including commuter rail and boat) due to a disability. The information you provide will allow the MBTA to make an appropriate evaluation of eligibility. To qualify for Paratransit service, an individual must meet at least one of the following criteria:

Category 1 Individuals who, as a result of a physical or mental impairment (including visual impairments), and without the assistance of another individual (except the operator) cannot board, ride, or disembark from an accessible transit vehicle.

Category 2 Individuals who can independently use accessible vehicles, but none are available on their route.

Category 3 Individuals who have a specific-impairment related condition that prevents them from independently getting to/from a stop.

A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure or Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if you want to provide more information.

Information which you provide will assist us in determining the applicant's functional ability to use public transportation. It is essential that you be precise and comprehensive. False or misleading information diverts resources away from persons legitimately qualified to use this program.

THE RIDE Paratransit Eligibility Form A:

Licensed Provider’s Form (General Medical)

Applicant’s Name:________________________________Date of Birth: _______ Applicant’s Address:_________________________________________________ Relationship to the applicant: _________________________________________ How long have you provided services/treatment for the applicant?___________

1. What is the medical condition that prevents applicant from accessing,

boarding, disembarking, and/or riding on the MBTA independently? (Note: MBTA fixed-route buses are 100% accessible. Eligibility criteria does not include age, inability to drive or that service would “benefit” the applicant.) ________________________________________________________________

2. Date of onset?____________________________________________________ 3. How does the applicant’s disability in combination with any barriers in the

environment, prevent the applicant from independent use of the MBTA fixed route services? ___________________________________________________ ________________________________________________________________

4. Does the applicant have the ability to travel in complex, crowded stations? Consider the station, time of day, accessibility of the station, etc.

Yes No Sometimes If no or sometimes, please explain: __________________________________ ________________________________________________________________

5. Is the applicant’s functional limitation permanent? Yes No If no, what is the expected duration? # of Months______ # of Years ______ Unsure ______

6. For safety reasons, should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes No If yes, please explain._________________________________________________________________________________________________________________________

MBTA RIDE GENERAL MEDICAL FORM A P1

7. For safety reasons can the applicant be left unattended at pickup or drop-off locations? Yes No If no, please explain_______________________________________________ ________________________________________________________________

8. Do you agree with the applicant’s self assessment on pages 1-7? Yes No

If no, please explain ______________________________________________ ________________________________________________________________________________________________________________________________

9. Is there any additional information about conditions/barriers that prevent

the applicant from using the fixed route some or all of the time ________________________________________________________________

10. Provider’s Checklist:

� I have provided a live signature (not photocopied, or stamped) � I have completed all contact info below, including a State Board

License # or Certification # ( not NPI, DEA).

I certify that the information given above is correct to the best of my knowledge. X______________________________________________________

Signature of Licensed Health Care or Human Service Provider

Clearly print your contact info below: CERT # or

NAME___________________________________BOARD LIC#_____DATE______ PHONE #_________________________________FAX # ____________________ BUSINESS ADDRESS _________________________________________________ EMAIL ____________________________________________________________

When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE Ten Park Plaza, Room 5750, Boston, Massachusetts 02116

THANK YOU FOR YOUR TIME AND INPUT.

MBTA RIDE GENERAL MEDICAL FORM A P2

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MBTA RIDE VISION FORM B THE RIDE PARATRANSIT ELIGIBILITY APPLICATION






A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure or Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if you want to provide more information.

Information which you provide will assist us in determining the applicant's functional ability to use public transportation. It is essential that you be precise and comprehensive. False or misleading information diverts resources away from persons legitimately qualified to use this program.

THE RIDE Paratransit Eligibility Form B: Licensed or Certified OMS Provider’s Verification Form (Visual Impairment)

Applicant’s Name:______________________________Date of Birth:____________ Applicant’s Address: ___________________________________________________ Relationship to the applicant:____________________________________________ How long have you provided services/treatment for the applicant? _____________

1. Please specify the applicant’s Visual Impairment:__________________________ 2. Date of onset _______________________________________________________ 3. Is applicant’s functional limitation permanent? Yes No

If no, what is the expected duration? # of months______ # of years______ unknown______

4. What is the prognosis? _______________________________________________ 5. Please note mobility aids used by applicant:______________________________ 6. Has the applicant received travel training to use the MBTA fixed route system

(buses, trolleys, trains)? Yes No unknown If yes, what were the outcomes? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

7. How does the applicant’s disability, combined with any environmental barriers, prevent independent use of the MBTA fixed route services? (i.e. buses, trolleys, trains) ____________________________________________________________ __________________________________________________________________ __________________________________________________________________

8. Please comment on the applicant’s ability to perform the following tasks: • Independently use a mobility aid ____________________________________________________________________ • Independently cross streets/intersections ____________________________________________________________________

• Independently travel in various conditions (lighting, weather, background noise) ____________________________________________________________________ • Independently navigate paths of travel, inclines, uneven terrain ____________________________________________________________________

MBTA RIDE VISION FORM B P1

• Independently orient oneself to surroundings, and plan or follow a route ___________________________________________________________________ • Independently detect stations/stops ___________________________________________________________________ • Independently navigate curbs/steps w/mobility device (if applicable) ___________________________________________________________________

9. For safety reasons should, the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes No If yes, please explain _______________________________________________ _________________________________________________________________

10. For safety reasons is the applicant able to be left unattended at pickup or drop-off locations? Yes No If no, please explain _______________________________________________ ________________________________________________________________

11. Any additional information about conditions/barriers that prevent the applicant from using the fixed route some or all of the time ______________________ ________________________________________________________________

12. Provider’s Checklist: � I have provided a live signature (not photocopied, or stamped) � I have completed all contact info below, including a State Board License # or

Certification # (not NPI, DEA). I certify that the information given above is correct to the best of my knowledge.

X____________________________________________________ Signature of Licensed Health Care or Human Service Provider

Clearly print your contact info below: CERT # or NAME_____________________________STATE BOARD LIC#______DATE _______ PHONE #______________________________FAX # _________________________ BUSINESS ADDRESS____________________________________________________ EMAIL ______________________________________________________________ When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE Ten Park Plaza, Room 5750, Boston, Massachusetts 02116

MBTA RIDE VISION FORM B P2

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MBTA RIDE EPILEPSY/SEIZURE DISORDER FORM C

THE RIDE PARATRANSIT ELIGIBILITY APPLICATION TO BE COMPLETED BY LICENSED/CERTIFIED

HUMAN SERVICE OR HEALTH CARE PROVIDER ONLY By completing and signing this document, you the health care professional, certify the truth and accuracy of the information provided on this application, to the best of your professional knowledge. The American with Disabilities Act of 1990 requires that the MBTA provide services to persons who are unable to use the fixed-route system (such as buses, trolleys, subway trains, not including commuter rail and boat) due to a disability. The information you provide will allow the MBTA to make an appropriate evaluation of eligibility. To qualify for Paratransit service, an individual must meet at least one of the following criteria:




A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Epilepsy or Seizure Disorder, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if you want to provide more information. Information which you provide will assist us in determining the applicant's functional ability to use public transportation. It is essential that you be precise and comprehensive. False or misleading information diverts resources away from persons legitimately qualified to use this program.

THE RIDE Paratransit Eligibility Form C: Licensed Provider’s Verification Form (Epilepsy or Seizure Disorder)

Applicant’s Name:________________________________Date of Birth: ___________ Applicant’s Address:_____________________________________________________ Relationship to the applicant: _____________________________________________ How long have you provided services/treatment for the applicant?_______________

1. Type of Seizure: ____________________________________________________ 2. Seizure Frequency: __________________________________________________ 3. Does the seizure alter consciousness or awareness? Yes No 4. Are the seizures preceded by an aura? Yes No 5. Are there any triggers to the seizures? Yes No

If yes, what are they? _______________________________________________ __________________________________________________________________

6. What behaviors are exhibited during/following the applicant’s seizure? ____________________________________________________________________________________________________________________________________

7. Is the applicant taking prescribed seizure medications that affect functional ability to independently use the MBTA fixed route services (bus, trolley, train)?

Yes No If yes, please note the effects of the medication. __________________________________________________________________ __________________________________________________________________

8. Is the applicant’s functional limitation permanent? Yes No If no, what is expected duration? # of Months_____ # of Years_____ unknown_____

9. What advice or limitations on independent travel have you communicated to the applicant?______________________________________________________ __________________________________________________________________

10. For safety reasons should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes No

If yes, please explain ________________________________________________ __________________________________________________________________ MBTA RIDE EPILEPSY/SEIZURE FORM C P1

11. For safety reasons can the applicant be left unattended at pickup or drop-off locations? Yes No

If no, please explain_________________________________________________ __________________________________________________________________

12. Please provide any additional information on the applicant’s ability to travel

independently on the MBTA fixed route services._________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________

13. Provider’s Checklist: � I have provided a live signature (not photocopied, or stamped) � I have completed all contact info below including a State Board License # Or

Certification # (not NPI, DEA). I certify that the information given above is correct to the best of my knowledge.

X____________________________________________________ Signature of Licensed Health Care or Human Service Provider

Clearly print your contact info below: CERT # or NAME_______________________________STATE BOARD LIC#________DATE______ PHONE #______________________________FAX # ___________________________ BUSINESS ADDRESS______________________________________________________ EMAIL ________________________________________________________________ When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE Ten Park Plaza, Room 5750, Boston, Massachusetts 02116

THANK YOU FOR YOUR TIME AND INPUT.

MBTA RIDE EPILEPSY/SEIZURE FORM C P2

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MBTA RIDE COGN/MH FORM D THE RIDE PARATRANSIT ELIGIBILITY APPLICATION






A licensed/certified human services or health care provider only needs to complete ONE Provider Verification Form: A-General Medical, B-Visual Impairment, C-Seizure or Epilepsy Disorders, D-Cognitive or Mental Health disabilities. It is optional to submit additional completed verification forms if you want to provide more information. Information which you provide will assist us in determining the applicant's functional ability to use public transportation. It is essential that you be precise and comprehensive. False or misleading information diverts resources away from persons legitimately qualified to use this program.

THE RIDE Paratransit Eligibility Form D:

Licensed Provider’s Verification Form (Cognitive or Mental Health Conditions) Applicant’s Name: ________________________________ Date of Birth:___________ Applicant’s Address: _____________________________________________________ Relationship to the applicant:______________________________________________ How long have you provided services/treatment for the applicant?________________

1. What is the applicant’s diagnosis (DSM-IV)? ______________________________ 2. Date of onset? ______________________________________________________ 3. What is the prognosis? _______________________________________________ 4. Is the applicant taking medications related to this disability that affect functional

ability to independently use the MBTA fixe route services? Yes No a. If yes, please describe the effects of the medication. ___________________________________________________________________ ___________________________________________________________________

5. Is the applicant receiving treatment/therapy that affect functional ability to independently use the MBTA fixed route services? Yes No a. If yes, please specify treatment/therapy and indicate an expected duration. Treatment_________________________Duration__________________________ Treatment_________________________Duration__________________________

6. Is the applicant’s disability the same every day? Yes No

a. If no, please explain ________________________________________________ ____________________________________________________________________________________________________________________________________

7. Are any of the following affected by the individual’s disability? Check all that

apply. _____Orientation _____Concentration _____Monitoring time _____Problem-solving _____Coping Skills _____Judgement _____Short term memory _____Communication _____Gait or balance _____Long term memory _____Consistency _____ Social behavior _____Aggression _____Performance _____Other __________________________________________________________ MBTA RIDE COGN/MH FORM D P1

8. Please explain how the above interferes with safe travel? ____________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________ 9. Describe how the applicant’s disability affects his/her ability to independently

complete the following travel tasks:

• Orient oneself to environment ________________________________________ • Travel alone outside _________________________________________________ • Leave the house on time _____________________________________________ • Seek and act on directions ____________________________________________ • Find way to/from bus stop or station ___________________________________ • Cross streets _______________________________________________________ • Wait for a bus or subway train _________________________________________ • Board correct bus or subway train ______________________________________ • Ride on a bus or train ________________________________________________ • Transfer to a second bus or train or exit at the correct destination

__________________________________________________________________ • Understand time and follow a schedule__________________________________ • Know when he/she is lost_____________________________________________ • Get help if he/she is lost______________________________________________ • Recognize and avoid dangers __________________________________________

10. Please provide information on how the applicant’s disability, combined with

any environmental barriers, prevent independent use of the MBTA fixed route services? (bus, trolley, train) ______________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________

MBTA RIDE COGN/MH FORM D P2

11. For safety reasons should the applicant travel (on THE RIDE) at all times with a personal care attendant (PCA)? Yes No

If yes, please explain.__________________________________________________ ____________________________________________________________________ ____________________________________________________________________

12. For safety reasons is the applicant able to be left unattended at pickup or drop-off locations? Yes No

If no, please explain___________________________________________________ ____________________________________________________________________

13. Is there any other information that would be an indication of the applicant’s

inability to independently use fixed-route public transportation? ____________________________________________________________________ ____________________________________________________________________ 14. Provider’s Checklist:

� I have provided a live signature (not photocopied, or stamped) � I have completed all contact info below including a State Board License # or

Certification # (not NPI, DEA).

I certify that the information given above is correct to the best of my knowledge.

X___________________________________________________ Signature of Licensed Health Care or Human Service Provider Clearly print your contact info below: CERT # or NAME_______________________________STATE BOARD LIC#________DATE_______ PHONE #______________________________FAX # ____________________________ BUSINESS ADDRESS_______________________________________________________ EMAIL _________________________________________________________________ When application is fully complete, please mail signed original to: MBTA Office for Transportation Access/ THE RIDE Ten Park Plaza, Room 5750, Boston, Massachusetts 02116 THANK YOU FOR YOUR TIME & INPUT. MBTA RIDE COGN/MH FORM D P3

Business

The ride application